Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.

 

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Dear Dr. Pat

I am fifty years old and an adjunct instructor at a small college in the northwest where I work part time. I used to love my work.  I am married with two late-in-life middle school children and am in menopausal hell. I have unpredictable hot flashes and night sweats.  I lose my focus when teaching or counseling a student.  I expend enormous energy managing my moods. I find that I need two glasses of wine most nights just to get through dinner. I can’t believe that I am trapped with young children, a no longer rewarding job, and a good enough marriage to a man who is thoughtful and a good provider but who has expectations of behavior that I am having trouble living up to.
I could ruin my professional life, my personal life, my marriage and my daughter’s lives if I don’t get my menopause under control. I don’t care about vaginal dryness and bone loss.  I need to function. 
I saw my holistic nurse practitioner (NP) twice in the last three months.  She did all the right blood tests and told me that everything was normal and that I was in late peri-menopause. All she offered me  was “life style change”—better nutrition, more exercise, meditation, and of course, vaginal estrogen for the genital atrophy. My NP is about forty and is staunchly opposed to hormone use.  I never thought I would be one of those women who needed to take estrogen but I don’t see how I am going to get through this without something.  I don’t have any personal or family  history of cancer or heart disease.  Is hormone replacement as dangerous as I have heard that it is? And don’t tell me to see a shrink.  I don’t have the time.
Ruth
Dear Ruth,
Women who had fulfilling  professional and personal lives first, then had children later in life, often find themselves in the menopausal transition with demands for the care of younger children, personal relationships, and work that leaves no time for self care. Something has to give, Ruth.    First, you should see another health care professional who will listen to your symptoms of menopausal syndrome and the narrative of your day-to-day existence. Find someone who will work with you to design a plan for evaluation and treatment of your symptoms.
Low dose estradiol and progesterone are a reasonable choice for someone with your significant symptoms.  You are clearly aware that there are some risks associated with hormone therapy but use of low dose preparations for a limited period of time is appropriate. Hormone therapy should decrease the hot flashes which may help with sleep. Improved sleep may lead to improvement in cognitive ability and mood swings.  If hormone therapy does not control the mood swings and the negative way of  looking at your life, then you will need further evaluation of this mood disorder.
The NP you saw was right in recommending exercise, thoughtful eating to control blood sugar, and meditation to improve sleep and concentration.  In addition, I strongly encourage you to stop all alcohol for the next six months.  Alcohol won’t fix your moods and it may impede cognitive function and  make sleep worse.  . Hormone therapy  and some small life style changes may not work if you can’t make real adjustments in the rest of your life. You describe everything in your life, at this point, in a negative way, Ruth. I do encourage you to see a therapist for help in creating a more manageable life.  Your work is part time and at this point you describe it as not rewarding.  Perhaps this is an area of your life that where you can find more time.
Each generation of women who enter the menopausal transition faces its unique challenges.  The women in Gail Sheehy’s The Silent Passage were the women who were given estrogen whether they had symptoms or not. The pharmaceutical industry and doctors added to the shame that surrounded the word menopause by promoting the use of drugs to keep women “forever young.” Women of your generation, Ruth, understand that medical management of menopause is a choice but not a necessity. The good news, then and now, is that most women have mild manageable symptoms that are temporary.  Patients who have significant symptoms do best with an individualized approach with reassurance that this transition is normal and transitory.  

 

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